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Hospital Customer Survey
Have all your patients fill out this Hospital Customer Survey. We need to get immediate feedback on every patients experience when they stay overnight at the hospital. No patient should leave the hospital without filling out this Hospital Customer Survey and turning it into their floor nurse.

Free Sample Template
Format: Word PDF
# of Pages: 5
Printable: Yes


Hospital Customer Survey TemplateForm 1408
Format: Word PDF
Category: Medical, Hospital
Type: Customer Survey

Hospital Customer Survey

We thank you in advance for completing this survey. When you have finished please turn it into your admitting nurse.

INSTRUCTIONS: Please rate the outpatient surgery you received from our facility. Circle the number that best describes your experience at our facility. Please skip the question if it does not apply to you and leave it blank. Space is provided for additional comments on positive or negative things that happened to you.

Sample Scale: Please use this scale when answering the questions.

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Rating Scale =

Very Poor

Poor

Fair

Good

Very Good

Registration :

1. If you spoke with the S2urgery Center by phone, please rate the helpfulness of the person you spoke with.

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2. Ease of getting an appointment for surgery when you wanted.

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3. Information you received prior to surgery (example, time of surgery, how to prepare).

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4. Helpfulness of the person at the registration desk.

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Comments (Please describe good or bad experience): __________________________________________________

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Facility :

1. Comfort of the registration waiting area.

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2. Comfort of your room or resting area in the Center.

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3. Comfort of the waiting area for your family.

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4. Attractiveness of the Surgery Center.

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5. Cleanliness of the Surgery Center.

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Comments (Please describe good or bad experience): __________________________________________________

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Before your surgery or procedure :

1. Waiting time before your surgery or procedure began.

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2. Friendliness and courtesy of your surgeon.

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3. Explanation the surgeon gave you about what the surgery or procedure would be like.

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4. Friendliness and courtesy of the nurses.

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5. Skill of the nurse starting your IV.

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6. Information nurses provided to you on the day of your procedure.

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7. Your confidence that the operating room staff correctly identified you and your procedure prior to surgery.

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Comments (Please describe good or bad experience): __________________________________________________

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After your surgery or procedure :

1. The nursesí concern for your comfort after the procedure.

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2. Information the surgeon provided about what was done during your surgery or procedure.

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3. Nursesí courtesy toward family who accompanied you.

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4. Information nurses gave your family after your surgery or procedure.

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5. Instructions nurses gave about caring for yourself at home.

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6. Your confidence in the skill of the nurses.

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7. Your confidence in the skill of the surgeon.

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Comments (Please describe good or bad experience): __________________________________________________

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Personal Issues :

1. Information provided about delays.

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2. Our concern for your privacy.

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3. Degree to which your pain was controlled.

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4. Response to concerns and complaints made during your visit.

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5. Extent to which staff washed their hands or performed hand hygiene.

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6. Your confidence that the staff provided care in a safe and secure manner.

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7. Extent to which nurses checked your ID bracelet before giving you medications.

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Comments (Please describe good or bad experience): __________________________________________________

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Overall Assessment :

1. Overall rating of care that you received during your visit.

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2. Degree to which the staff worked together to care for you.

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3. The likelihood of your recommending our Ambulatory Surgery Center to others.

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Comments (Please describe good or bad experience): __________________________________________________

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Optional Patientís Name: _________________________________________________________________________

Optional Patientís Phone Number: _________________________________________________________________

Thank you for completing this survey.